Breastfeeding is not always possible after birth, or women may make a personal choice not to breastfeed. When milk is not regularly removed from the breast, milk production eventually ceases. In the meantime women may require specific education and support to minimise discomfort, pain and leakage of milk and to prevent the risk of engorgement or mastitis.

• To suppress lactation in mothers who are not breastfeeding due to medical, personal or social reasons.

• To minimise the discomfort that some mothers may experience when suppressing lactation.

 All staff who provide care for new mothers.

Abrupt, unplanned weaning or suppression can be stressful for the mother. Many women experience strong emotional responses to suppression and will benefit from appropriate counselling and support. Support services should be sourced for the woman and her family based on individual needs.

Support Services include:

• Australian Breastfeeding Association 24 hour helpline 1800 686 268 and website www.breastfeeding.org.au.

• BHS Breastfeeding Clinic Ph 53204977.

• BHS/Parent Place Breastfeeding Support (Thursdays only).

• BHS Clinical Midwife Consultant for Lactation Ph 53206871 mob 0439981937.

• Maternal and Child Health Nurse.

• 24 Hour Maternal and Child Health Advice Line 132229.

• General Practitioner.

Physiological suppression of lactation is generally uncomplicated and is recommended as a first line approach over pharmacological suppression due to potential side effects associated with medication.

Some reasons why a mother may suppress lactation include;

• Personal choice.

• Pregnancy loss or stillbirth.

• Death of a newborn baby or breastfed child.

• Adoption.

• Maternal or infant medical conditions where breastfeeding may be contra-indicated.

• Infant self weans unexpectedly.

• Unresolved difficulties with breastfeeding.

Consumer information

Provide the mother with a copy of the Consumer Information Document CID0002 Breastmilk Suppression if appropriate.

1. Suppression of lactation immediately following birth

• The breasts should be well supported immediately postpartum with a firm, but not tight bra or crop top worn day and night.

• Avoid breast stimulation, however if the breasts become uncomfortably full or painful the mother may need to hand express a little milk occasionally for comfort. Ensure the mother has been taught how to hand express.

• Advise the mother the process varies but generally discomfort may last only 24-72 hours.

• Inform the mother that some milk leakage may occur and breast pads may be required.

• Application of covered, cold compresses (such as frozen nappies) and use of analgesia may alleviate pain.

• Observe breasts for signs of inflammation, lumps or painful areas.

2. Suppression of lactation when lactation is established.

• Suppression should be gradual over a period of a week to a month depending on the stage of lactation and milk supply.

• Abrupt suppression should be avoided as this is associated with an increased risk of mastitis and breast abscess.

• If the mother is breastfeeding, - refer to Section 5- Planned weaning/gradual suppression, as below.

• If the mother is expressing, gradually reduce the frequency and length of expressions, ceasing when expressing only once a day and minimal amounts are expressed.

• Avoid suppression if mastitis is present as this may increase the risk of breast abscess. Advise the woman that mastitis is NOT an indication to suppress. Refer to CPG0161 Breastfeeding Challenges - Mastitis and breast Abscess.

3. Suppression of lactation after stillbirth, foetal death or neonatal death.

• Parents should be informed that some breastmilk production may commence from around 16 weeks gestation.

• Sensitive and open discussions should be held with the parents regarding options for suppression.

• Some women view lactation following perinatal loss as part of their grieving process rather than something to be avoided.

• Some women request pharmacological suppression at this time, and information should be given regarding possible side effects of medication.

• If the baby has been stillborn, physiological suppression guidelines as per section 1 above can be followed.

• If the baby has died after lactation is established, physiological suppression guidelines as per section 2 above can be followed, gradually suppressing by expressing.

4. Pharmacological suppression - information from the Therapeutic Guidelines

Pharmacological suppression of lactation is not routinely advised due to potential side effects of medication. Side-effects of cabergoline may include dizziness, headache, nausea and hypotension.

If pharmacological suppression is required, or a mother has requested medication to suppress, the following guidelines from the Therapeutic Guidelines should be followed (Therapeutic Guidelines 2022)

Drugs are used in conjunction with nondrug methods to prevent (or rapidly suppress) lactation in the following situations:

• Stillbirth or neonatal death.

• An infant being placed for adoption.

• Personal choice not to breastfeed.

• Medical conditions in which breastfeeding is not advised, such as:

  • Severe morbidity when the individual is too unwell to breastfeed.

  • Use of drugs contraindicated in breastfeeding, such as antineoplastic drugs or monoclonal antibodies; see the Drugs and Lactation Database (Lactmed) or advice from a Medicines Information Service.

  • HIV infection (regardless of plasma HIV viral load).

Dopamine agonists such as cabergoline and bromocriptine can be used to suppress lactation. Cabergoline is the drug of choice, as it has a longer half-life (so can be taken as a single dose) and has a lower rate of rebound lactation. It also has fewer adverse effects than bromocriptine, which is associated with rare but severe effects such as maternal stroke, seizures, cardiovascular disorders, psychosis and death.

Dopamine antagonist antiemetics commonly used in the postpartum period, such as metoclopramide, prochlorperazine and promethazine, can reduce the prolactin-lowering effects of cabergoline; cabergoline should not be taken until at least 4 hours after metoclopramide, prochlorperazine or promethazine.

Obstetric contraindications to cabergoline include pre-eclampsia and postpartum hypertension. Use cabergoline with caution in individuals with kidney disease, Raynaud phenomenon, gastrointestinal bleeding, a history of psychosis, or postpartum hypotension.

Cabergoline can be used for lactation suppression at any point after delivery, but is most effective if given within the first 12 hours.

If lactation is not yet established, use:

•  Cabergoline 1 mg orally, as a single dose.

Rebound lactation can occur 1 to 2 weeks after taking cabergoline. Supportive care for lactation suppression is usually adequate to manage this; however, an additional short course of cabergoline may be required. Use:

•  Cabergoline 250 micrograms orally, every 12 hours for 4 doses.

If lactation has been established, gradual suppression of lactation is advised to reduce the risk of mastitis and breast abscess formation. Use:

• Cabergoline 250 micrograms orally, every 12 hours for 4 doses.

Further courses of cabergoline can be used, but are rarely required when treating individuals with established lactation.

In all situations where lactation is being suppressed, advise against breastfeeding or expressing milk after taking cabergoline, as either could stimulate lactation. It is not known if cabergoline is secreted in human milk.

5. Planned weaning/gradual suppression

• Slowly replace each breastfeed with an infant formula feed.

• Gradually reducing the number of breastfeeds every few days or one feed per week will reduce the risk of breast discomfort.

• Commence with replacing one feed every few days and if no discomfort or engorgement occurs, replace a second feed and so on.

• If the breasts become full and uncomfortable express by hand or pump only enough to relieve the discomfort.

• Watch for signs of mastitis including inflammation, fever, breast lumps and/or painful areas on the breasts.

 6. Safe use of infant formula

When lactation is suppressed, women should be taught how to safely prepare, store, use and transport infant formula. Refer to CPP0402 Formula Feeding of the Healthy Term Newborn. Provide the mother with a copy of the Consumer Information Document CID0018 A Guide to Infant Formula and Bottle Feeding (see related documents).